Pitched upon a pitchfork

After countless hours reading dreadful stories in medical journals I’m rarely shocked by a case, but this one [no need to stop reading – there’s a happy ending!] really gave me pause for thought. It was reported in The American Journal of the Medical Sciences in 1853, by one Dr. Sargent from Worcester, Massachusetts:

A lady, of about 37 years of age, who had borne several children, the last about three years previous to the injury about to be mentioned, and whose last menstrual period had been about a week before, her bowels also being in good lax condition…

As far as I can see, neither of these aspects of her medical history have much relevance to what follows.

…in sliding down from a hayloft, impaled herself upon the handle of a pitchfork, which passed in at her vagina to the length of twenty-two inches, when her feet struck the ground.

Twenty-two inches! Almost two feet, or 55 cm. It travelled a considerable distance into her abdomen.

The handle was immediately withdrawn, the patient carried into the house, and Dr. S. sent for. He found the patient, half an hour after the injury, lying on her back, with the thighs flexed, and the skin cool, pale, and moist (as if from fright), and the pulse not much accelerated.

I think I’d be frightened too.

There was no external injury, and no physical evidence of effusion into abdomen or thorax, and no urine nor feces on the garments, nor about the person, nor on the field of the accident, nor on the handle of the fork. There was some blood flowing from vagina. Patient passed water during the visit, and it was not stained with blood. She complained most of pain in the left thorax, on a line with the scapula.

It’s pretty surprising that there was so little sign of injury. There was a serious danger of internal bleeding, of course, which might not be obvious externally.

Dr. S. saw the handle of the fork, which was rounded, a little larger at the end than otherwhere, perfectly smooth, two inches in diameter, and showed distinctly the stain of blood up to an abrupt line, twenty-two inches from the end.

I’m still wincing.

Dr. S. theorized, in this case, that the instrument must have perforated the vagina at its upper part to the left, and gone between the uterus and rectum. If it had gone to the right, it would have perforated the caecum.

Part of the bowel, at the junction between the large and small intestines. Puncturing it might have had dire consequences – the release of bowel contents into the abdominal cavity would have been a recipe for infection.

The form of the instrument would make it much easier for it to pass between than to perforate organs, and Dr. S. supposed that it passed in front of the kidney, behind the spleen and between the diaphragm and false ribs, peeling up the costal pleura till it reached the scaleni muscles.

The scalene muscles (formerly known as the scaleni) are at the side of the neck. Dr Sargent believes the pitchfork went all the way into the thorax, narrowly missing the lungs – and every other major structure of importance.

The subsequent history of the case, which showed a fracture of the first rib, while, also, there was at no time any effusion into the chest, proved this diagnosis correct.

A truly astounding injury.

Supposing that the greatest safety of the patient was in what might be called forced rest, Dr. S. gave her one grain of morphia (by estimate), and bound her chest firmly with a broad bandage of new flannel, placing a towel, wet in cold water, between this and the skin. The morphia was repeated in an hour, and one-third of a grain three hours after. Patient passed water repeatedly in first twentyfour hours, without trouble and without blood, and passed coagula [clots] from the vagina.

The only apparent complication from this injury was some slight swelling above the left collarbone the following day, and some minor irregularities in the breathing sounds – probably caused by the rib fracture and accompanying inflammation.

The injury was inflicted the 7th of August, 1851, and Dr. S. was in daily attendance for nine days; and, occasionally, afterwards, for three weeks. The recovery was entirely favourable, the patient being left only with an ill-united fracture of the first rib, over which there was some painful swelling for several weeks, which ultimately subsided, leaving an osseous prominence in the supraclavicular region, in intimate relations with the scaleni muscles.

Strangely, Dr Sargent makes no mention of the primary wound in the vagina, through which the pitchfork handle entered the abdominal cavity. This might have proved a site for infection, or proved difficult to heal, but apparently not. By any standards – modern or otherwise – this must count as one of the luckiest escapes on record.